Updated ACG GERD Guideline Addresses Increased Scrutiny of PPI Therapy
December 3, 2021 — For the first time since 2013, the American College of Gastroenterology (ACG) has released updated evidence-based guidelines and practice guidelines for the evaluation and management of gastroesophageal reflux disease (GERD), including pharmacological, lifestyle, surgical, and endoscopic management.
While PPIs remain the “drug of choice” for GERD, numerous studies raise questions about side effects, they note.
“Now we know a lot more about the side effects of PPIs in the sense that we have 8 more years of experience,” says first author Philip O. Katz, MD, professor of medicine and director of the Weill Cornell Medicine Motility Laboratories, New York.
This update emphasizes the importance of an accurate diagnosis and recommends PPI therapy “when patients do have GERD and are trying to use the lowest effective dose,” says Katz.
The guide was posted online on November 22 at the American Journal of Gastroenterology.
The benefits outweigh the risks
The guidelines suggest informing patients that PPIs are the most effective treatment for GERD.
Several studies have found an association between long-term PPI use and the development of a number of adverse conditions, including intestinal infections, pneumonia, stomach cancer, bone fractures associated with osteoporosis, chronic kidney disease, certain vitamin and mineral deficiencies, heart attacks, strokes, dementia, and early death.
However, clinicians should emphasize that these studies are flawed, not considered conclusive, and do not establish a causal relationship between PPIs and adverse conditions.
They should also draw patients’ attention to the fact that high-quality studies have shown that PPIs do not significantly increase the risk of any of these conditions other than intestinal infections.
Patients should be advised that for the treatment of GERD, “gastroenterologists generally agree that the generally recognized benefits of PPIs far outweigh their theoretical risks.”
“Everything about this guideline makes sense,” says Scott Gabbard, MD, a gastroenterologist, and department head at the Cleveland Clinic Center for Neurogastroenterology and Movement, who was not involved in the development of the guideline.
“Trialing a PPI for everyone with typical GERD symptoms and those responding to reduction to the lowest effective dose is still the first line for everyone with GERD,” says Gabbard.
Because there is no gold standard for diagnosing GERD. The guidelines state that the diagnosis is based on a combination of symptoms, endoscopic evaluation of the esophageal mucosa, reflux monitoring, and response to therapeutic intervention.
For patients with classic symptoms of heartburn and regurgitation without anxiety symptoms, the authors recommend an 8-week course of empirical PPI once daily before meals. If the patient responds, the guideline recommends trying to stop the medication.
The guidelines recommend exploratory endoscopy after PPI discontinuation for 2-4 weeks in patients whose classic symptoms do not respond adequately to an 8-week empiric PPI study or those whose symptoms return after PPI discontinuation.
For patients with chest pain but without heartburn who have had an adequate evaluation to rule out heart disease, the guidelines recommend objective testing for GERD (endoscopy and reflux monitoring).
The use of barium swallow solely as a diagnostic test for GERD is not recommended.
Endoscopy should be the first test to evaluate patients with dysphagia or other worrisome symptoms such as weight loss and gastrointestinal bleeding, and for patients with risk factors for developing Barrett’s esophagus.
The guidelines recommend against off-therapy reflux monitoring solely as a diagnostic test for GERD in patients with known endoscopic evidence of Grade C or D reflux esophagitis in Los Angeles (LA) or patients with a long segment of Barrett’s esophagus.
High-resolution manometry solely as a diagnostic test for GERD is also not recommended.
GERD Medical Directorate
Recommendations for medical treatment of GERD include weight loss in overweight or obese patients, fasting 2-3 hours before bedtime, avoiding tobacco and trigger foods, and raising the head of the bed for nocturnal symptoms. PPI treatment is recommended in place of histamine 2 receptor antagonists to heal and maintain healing of eosinophilic esophagitis. It is recommended that you take a PPI 30 to 60 minutes before a meal, not at bedtime.
There is a “conceptual rationale” for testing PPI switching for patients who do not respond to one PPI. However, switching more than once to a different PPI “may not be supported,” the manual says.
Gabbard said the advice to switch PPIs in non-responders is especially helpful.
“In clinical practice, I see patients who try one PPI, and if it doesn’t work, their doctor puts them on another PPI, then another, and another until they take five PPIs and get nowhere,” he says.
“It is very helpful in this new guidance to say that if a patient has GERD symptoms that do not respond to PPIs, you can make one transition whether the patient actually has reflux or not,” says Gabbard.
“Some studies have shown that up to 75% of patients who do not respond to PPIs do not actually have reflux. They have functional heartburn, which is not refluxed and is treated without a PPI,” he notes.
The guidelines “do not make clear recommendations as to whether weaning or stopping cold PPIs is the best approach due to lack of evidence,” says Katz.
For patients with GERD without erosive esophagitis or Barrett’s esophagus whose symptoms resolve with PPI therapy, the guidelines say to attempt to discontinue PPI therapy or switch to on-demand therapy, in which PPIs are taken only when symptoms appear and stopped when they are are relieved.
For patients with grade C or D LA esophagitis, indefinite maintenance PPI therapy or antireflux surgery is recommended.
Gabbard said it was “gratifying to receive a written message from the ACG that patients with erosive esophagitis or Barrett’s esophagus – those who do need PPIs – should receive indefinite PPI therapy because the benefits of PPIs far outweigh the theoretical risks.”
The study did not have financial support. Katz has served as a consultant for Phathom Pharma and Medtronic has received research support from Diversatek and honoraria from Up to Date and is on the advisory board of Medscape Gastroenterology. Gabbard has not disclosed any relevant financial relationships.